On behalf of all of us here at TPSC we hope this communication finds you and your families healthy and safe.
Federal legislation has been enacted to assist group health plan members with out of pocket costs for testing of COVID-19. This legislation affects all group health plans, including grandfathered plans. Many of the federal health changes are similar to those recently enacted in Washington State (and other states) by the OIC.
Treatment of COVID-19 is covered the same as any other condition, subject to the benefits, terms, and conditions of your existing Plan.
To comply with these orders and to ensure members needs are met, we are recommending the following updates as of January 1, 2020:
  • The new law requires group health plans to cover FDA-approved coronavirus testing and to waive cost sharing and any prior authorization requirement for testing. In addition to the test itself, this requirement applies to visits in physician offices or through telemedicine, urgent care centers, and emergency rooms associated with testing.
  • The new law requires group health plans to cover FDA-approved coronavirus testing and to waive cost sharing and any prior authorization requirement for testing. In addition to the test itself, this requirement applies to visits in physician offices or through telemedicine, urgent care centers, and emergency rooms associated with testing.
  • The WA OIC also mandated that plans allow an early refill of certain prescriptions. While this state mandate applies only to insured plans, early refills may be needed for members covered by self-insured plans who are advised to self-isolate or are under quarantine. Currently early refills are routinely allowed for vacation needs and this exception is being extended during the COVID-19 emergency.

    Each PBM may be handling early refills differently. If your plan member experiences any difficulty please have them contact our Member Services team for assistance at 800-426-9786, ext. 210. Associates are available M-F 7:30AM-5:00PM Pacific Time.
  • We are also recommending that any plan currently excluding telephone or electronic consultations (i.e. telemedicine or virtual visits) remove this exclusion. Many providers now routinely offer services via telephone or on-line and the rates are similar to, or less than, an in-person visit.

    During the COVID-19 outbreak, many providers have ceased all in-person appointments but are offering telephone and virtual visits to patients. Virtual appointments allow patients to continue treatment that may not otherwise be possible if they needed to visit the providers office or clinic.
YOUR ACTION IS NEEDED
  1. Please insert your company name and distribute the attached Summary of Material Modification (SMM) to your enrolled members, and
  2. Please contact your TPSC Account Manager to confirm your acceptance of removing the exclusion (if any) in your plan for telemedicine or virtual visits (NOTE: telemedicine and virtual visits will be covered for services associated with COVID-19 testing as mandated; by confirming your acceptance of removing the general exclusion (if any) you are confirming you accept coverage for telemedicine or virtual visits for other, non-COVID-19 related medical and mental health services provided by physicians)
We are preparing an Appendix for your plan to confirm coverage of COVID-19 testing and the early Rx supply provision and will send that to you as soon as possible. If you elect to also remove a general exclusion of telemedicine and virtual visits that may be in your plan, we will also include a Plan Amendment.
With so much focus on the diagnosis and treatment of COVID-19, it’s easy to forget what hasn’t changed. Although Plans must accommodate certain extensions of benefits, most of them remain the same.
With some businesses needing to adjust staffing using furloughs and layoffs, it is important to consider whether, or how, Plan benefits will be extended for your employees. In the TERMINATION OF COVERAGE section of your Plan Document, there are several options for extending coverage for employees depending on their status with the Company:
1. Termination or Layoff.
1. Coverage for Employees (and their Dependents) who are being terminated or laid off will continue to the end of the month (or as otherwise specified in your plan);
2. Paid Sick Leave.
2. If you are allowing your Employees to use their paid sick leave or vacation time during their absence from work, they are still Employees and would still be covered by the Plan, but would be responsible for continuing to pay their contribution;
3. Leave of Absence.
3. Some Employers have an internal Leave of Absence policy that would allow an Employer to be absent from work without losing coverage. Other leave options include the federal Family and Medical Leave Act (FMLA). Many states also have their own form of family and medical leave. These laws require that the Employee have the opportunity to continue their coverage during their leave so long as they make their contributions to the Plan. Depending on your company policy, these Employees’ contribution may be the full premium or some part of it.
Of course as the Plan Sponsor you could decide to address this situation in another way. If you choose to change your current plan provisions, please let us know so that we can provide you the necessary amendment and to assure that your Stop Loss carrier will accept the proposed change.
These are unprecedented times as the COVID-19 pandemic disrupts our lives and temporarily changes the practice of medicine and business. If there is anything we can do to support you and your enrolled members please reach out to us at 800-426-9786.
1101 Pacific Ave., Suite 300 // Tacoma, WA 98402 // 800.426.9786
www.tpscbenefits.com
TPSC
1101 Pacific Avenue, Suite 300, Tacoma, WA 98402, US